Welcome

Firstly, I’d like to thank xxx for allowing me to present at this conference.

This paper was originally intended to be presented at a very different time. December 2020 saw Fiji
largely free from COVID and my focus on the manner in which health strategic policy omitted culture
and a suggestion of how that impacted health outcomes particularly with a focus on non-
communicable diseases was at that time relevant. How things have changed in a few short months.

The circumstances Fiji now finds itself in are very different and the repeated postponements of this
conference, due to cyclones, floods, and now pandemic mirror the challenges Fiji has had to face
over the last six months. These are indeed unusual and challenging times.

In some ways, this is an unusual conference for me to present at. As a community and international
development monitoring and evaluation specialist, I would conventionally be more at home at a
development, evaluation or even an anthropological conference. After all, I am neither a health
policy expert and nor obviously am I trained in any medical discipline. So why am I here?

Background

The reason stems from an incident that occurred in 2017. A friend of mine, who I will call Mere, an
iTaukei woman from eastern Vanua Levu died from complications due to an untreated foot ulcer,
the result of type 2 diabetes.

I have been visiting the Udu point area of Fiji where Mere lives in for over 30 years and have come to
know the increasing level of devastation wrought by non-communicable diseases, type 2 diabetes in
particular. Like you no doubt, I have lost several friends from this disease, so in some ways I
shouldn’t have been surprised by Mere’s passing.

But in this case, something was different; Mere had refused care. Even though her husband,
children, and other community members, the nasi ni koro and later the nurse from the local
dispensary had pleaded with her to go to hospital for treatment, she was adamant. She would not
go. She even signed a document to this effect. So, my friend died in great pain, suffering terrible
indignity in her final hours.

This was very surprising. Mere was what we in the development world often look to, someone able
to straddle a traditional way of knowing and a commercial one often at variance with kinship
obligations, open to new ideas, able to challenge traditional gender roles yet remaining true to her
cultural heritage. She was a successful businesswoman, managing a small roadside canteen that did
a lively trade. She was proud of her achievement, and we would often discuss how she could make
her small business more profitable. I had not known she was diabetic. I thought of anyone I knew
she would be one who would embrace medical care.

So why had a woman who in other ways was able to straddle different ways of knowing in this case
been unable to do so with catastrophic results was something I wanted to understand.

Initial research question

I knew from conversations with my many itaukei friends that while I understood most of their values
and those I didn’t I could accept, when it came to health and wellbeing, I was unable to penetrate
their world view. As I am sure is familiar to many, not just the types of herbal or other cures were
different, but the descriptions of illness and critically the causes of illness were at variance to mine.
So, what to do with this knowledge? A chance meeting with an Australian health Anthropologist
introduced me to the idea of medical pluralism. Simply put, this is the concept that people often
access multiple health systems in either a systematic or haphazard manner. It might be the handed
down herbal treatment for a particular condition that is used instead of expensive medicines. It
might be a more formal system such as xxxx in India. But it might be where the question of disease
causality is informed not just by the physical manifestations of the disease but by a whole set of
aspects that reflect an epistemology that emphasises connectivity between the physical, spiritual,
cultural worlds at variance with a biomedical approach.

At this stage it is important I emphasise this paper is not in defence of complementary medicine or
other medical practices. Instead, I want to make the point that biomedicine stems from a particular
reductionist epistemology. It inhabits that world and makes sense in that world but critically, not
everyone sees health, sickness, and wellbeing in the same light. I think it reasonable to conclude for
many itaukei people, disease causality and treatment is something that is likely to be understood
within competing and at times complementary modalities.

So, I thought it reasonable that healthcare in Fiji would recognise that many amongst its midst would
have a different way of understanding wellness and illness and policies and protocols and practices
would reflect this reality. After all many if not most doctors, nurses, health administrators and health
policy writers were themselves iTaukei, no doubt far more familiar with iTaukei epistemology and
ontology than I.

I had intended to conduct some field work into medical pluralism whilst in Fiji on an AVI
secondment, but Covid intervened making that impossible, so I decided focus on health strategic
policy examining the extent to which cultural practices inform health policy in Fiji. The 2020-25
Ministry of Health and Medical Services Strategic policy had just been released so that seemed like a
perfect document to analyse.

I quickly hit a snag. Cultural values were not discussed in the policy at all.

I wanted to understand why this was the case. So instead of a paper describing the extent to which
culture informed health policy in Fiji I was now focusing on what did inform the policy.

When it came to methodology, conventional analytical techniques such as critical discourse analysis
were not found to be suitable. I was interested in who got to speak and who didn’t, not how
language was used to demonstrate power. I wanted to understand the underlying ideas that
informed the policy which prima facie made no sense to me. (6:00)

WPR What’s The Problem Represented to Be?

Carol Bacchi’s “What the Problem Represented to be” is a form of critical discourse analysis which
takes its departure point from the concept that governments don’t just solve problems, they create
problems which they in turn try to solve, a process Bacchi calls problematization.

Problematization

Another way to explain this is to say that governments, through policies they create, engage in
problematization, defined by Bacchi as being ‘the products of government practices, that is, how
issues are problematized’ (Bacchi, 2012).

A simple example might be a policy that focuses on physical activity for young people who are
overweight. It is problematizing lack of exercise as a cause of childhood obesity and is seeking to
ameliorate this phenomenon through policies that address physical inactivity. In other words, it has
problematized lack of physical activity. To have done so, certain assumptions must exist for the
government to act in such a way and not target other potential causes of obesity such as food
advertising, diet, or social factors unrelated to exercise. This has particular relevance to
understanding healthcare in Fiji. To make sense of the rationale which informs current policy, it is
necessary to understand the assumptions upon which such policies exist, and critically, to
understand what unexamined ways of thinking upon which the accepted practices are (presumably)
based.

Bacchi’s methodology is centred around a set of seven questions, the first four of which are used
here. They focus on unexamined assumptions which sit behind such problematizations, the logic
necessary for the problematization to make sense, what silences are there, who is and isn’t being
heard, and what alternative ways of describing the problem might exist

ANALYSIS

Access to healthcare is the principal barrier to people seeking healthcare in a timely manner

The policy appears to be based on the problematization that access to healthcare is the principal or
only barrier to people seeking healthcare in a timely manner. This is informed by two underlying
assumptions, that expertise sits solely with medical authorities, and culture plays no part in
understanding health outcomes.

Given well over two thirds of the population live on the main islands for whom a secondary or
tertiary healthcare facility is relatively accessible by public transport, the high rates of late diagnosis,
a recognised cause of complications, the expansion of subdivisional hospitals and medical centres
whilst laudable is alone unlikely to have a large effect on late presentations.

This discourse relies on a binary of remotely located and urban healthcare consumers as two
separate groups. The policy states there is a need to provide services closer to people's homes, but
no evidence is presented which suggests how this conclusion was arrived at. As the implication is
that there is a population who didn't access care at all, what research that could be done was only
conducted on those who actually presented for care at some point, meaning those that didn't
present cannot be included in the data.

This has the effect of silencing those who should trouble health professionals the most: people who
never engage with the health system at all or do so haphazardly. The concept of survivorship bias, ‘a
logical error that leads to false conclusions by concentrating on the people or things that made it
past a particular selection process’ (Yeong, 2020), has relevance here as evaluations can only be
based on those who have presented for care. If this is the case, then it has deep implications for the
policy, as we are basing policy settings on those who already engage with the health system, not
enquiring why others are not.

But how did the current policy end up looking like it does, in apparent contrast to decades of
research from many parts of the world? A hint to this may lie in Fiji’s historical governance

Genealogy of Ideas

The colonial experience, never mind how benign, pits a colonising power with knowledge and
power, against a colonised population whose knowledge is undervalued, their voice silenced and
whose agency is curtailed save in the service of empire. For this to occur, other knowledges had to
be both supplanted and supressed.
What this amounted to in Fiji was a devaluation and eventual loss of much traditional knowledge as
the indigenous population were encouraged to adopt new ways.

In the field of healthcare, biomedicine, first practiced by colonisers but increasingly in the hands of
indigenous practitioners has supplanted old knowledge.

Little has changed since Fiji gained independence in 1971, A dominant Western biomedical system of
healthcare continues to enjoy a privileged status. It is a symbol of modernity.

Underlying assumption one: expertise sits solely with medical authorities

Thus, an underlying assumption in this strategic policy is that expertise sits solely with medical
authorities. The design approach of the strategic plan indicated that most of the consultation was
principally with health professionals. It was acknowledged that visits were made to communities, but
the key activities of participatory workshops were done it appears with health professionals alone. In
a culture where respect is generally shown to those in authority, it is unlikely that those members of
the public who were consulted, would be likely to be open in offering their opinions.

Throughout the design approach, the assumption is that expertise sits with healthcare professionals.
This can only make sense if the current approach is the only one that could be applied, therefore
there is no need to engage consumers to address questions already determined by those with the
expertise, or to answer research questions other than those posited by people formulating the policy

Ideas around medical pluralism, ‘a social practice that produces hybrid (i.e., a mixture of traditional
and modern) forms of medicine’ (Ferzacca, 2001 p 210) are silenced despite its presence in many
parts of the world (Baer 2011). Many have observed the pluralistic life of many people in modern Fiji
(Vunaibola, 2011; Meo-Sewabu, 2015; Naboro-Baba, 2006; Veitayaki, 2012), suggesting this might
also apply to the field of medicine

With the interlocking systems of post-colonial power structures and cultural traditions of silencing in
place we see the absence of the concept that people are experts in their own lives, which
subsequently appears to be a viable alternative way of framing the problem. A way to reframe this
might be to instead of simply calling upon medical professionals alone, consider how the combined
knowledge of medical professionals and others to whom people turn to, could best be employed for
the benefit of the entire population. Consequently, the fact that others besides MHMS staff might
have input into producing positive health outcomes is left unproblematic.

With this silencing of the holistic approach of indigenous healthcare, one which acknowledges the
interconnectedness of spiritual, physical, social, and environmental factors in a person’s wellbeing
(Dudgeon, 2014), the adoption of a reductionist approach is perhaps inevitable. Evaluation
methodologies that seek to reduce healthcare to a set of measurable KPIs (2/forward from the
permanent secretary) have the potential to atomise healthcare. To divide healthcare into promotive,
protective, and preventive care, separate from clinical care, (19/strategic priority 1) may appear
reasonable. However, research suggests that this perpetuates the overall problem of the separation
of the physical manifestation of disease from the complete experience of disease, including the
social role a person adopts or the process by which illness becomes a social event

Underlying assumption two: Culture plays no part in understanding health outcomes

Just as we see a silencing of people, their culture too is unacknowledged. Throughout the policy,
culture is mentioned only once and that in a negative fashion (8/2.2) as being a factor contributing
to poor outcomes for women, adolescents, and children.
The absence of the incorporation of culture in the policy suggests an assumption that cultural
practices are a barrier to good change.

Acknowledgement that cultural practices can also be life affirming or even relevant is absent, as is
the concept of culture being more than a set of practices. Rather than seeing culture as an
overarching set of values and ways of seeing the world, something in which all aspects of a person’s
life have meaning, a singular part of cultural practice is isolated and critiqued.

It is clear that by not acknowledging cultural factors, the strategic policy is running at odds with this
framework. Also, the Declaration on the Rights of Indigenous People (UNGA, 2007) in article 23
states: ‘indigenous peoples have the right to be actively involved in developing and determining
health, housing and other economic and social programmes affecting them and, as far as possible, to
administer such programmes through their own institutions’ (UNGA, 2007, p. 18) Fiji is also a
signatory of the Yanuca declaration (WHO, 1995) whose undertakings are outlined in its Healthy
Islands Framework (WHO, 2015). That framework specifically calls upon signatories to enable health
issues to be addressed ‘in partnerships among communities, organizations and agencies at local,
national and regional levels’ (Galea, 2000, p. 170). For this to be the case it would be presumed that
policy makers would not only consult stakeholders, but actively seek to engage communities in all
levels of planning, something about which the document is silent.

In other words, the integrated understanding of health and wellbeing consistent with iTaukei culture
is in fact embedded in several of the key conventions to which Fiji is a signatory. A question that
emerges is: would it be possible to integrate culture as discussed in the two conventions mentioned
above with health delivery in Fiji?

Conceiving the problem differently

As it happens, Fiji has a well-developed traditional iTaukei structure which sits alongside government
administration. Each village has a traditional hereditary leader turaga ni vanua as well as a voluntary
local government representative turaga ni koro (village headman) and a voluntary nasi ni koro
(community health worker). This structure is ripe for exploitation in integrating both sides of
community leadership, the traditional and administrative, in creating integrated health programs
that acknowledge traditional knowing as well as biomedical knowledge, much as occurs today in
rural Australia with Ngangkari workers where traditional health practitioners help bridge the gap
between two vastly diverse cultures.

The policy is silent on the concept of cultural safety as a factor which might influence the uptake of
both preventative and clinical care. Evidence from Australia and New Zealand suggests that
incorporation of cultural safety within an ethic of care is important in producing positive outcomes,
whilst Siversten’s concept of ‘two eyed seeing’ focuses attention on spirituality as a ‘powerful
determinant of health’ amongst older indigenous Australians.

Cultural safety and two eyed seeing posits cultural practices as supportive and life affirming; that
culture is defined by not just a series of practices but represents a range of values and attitudes as
well as actions and behaviours.

The WPR analysis revealed the concept of medical pluralism to be absent from the strategic policy.
Many iTaukei people practice a form of medical pluralism, seeking healthcare from several sources,
of which the MHMS is but one. The literature review revealed there has been little research as to the
extent this occurs, and why, and we also do not know what the impact of people’s health practices
on their health outcomes is. Are there instances when people will seek care early and others where
they do not? Do some people manage to incorporate iTaukei systems of causation with biomedical
treatments, and some not?

Determinants of health have been shown to be key to good health and wellbeing The strategic policy
explicitly focuses on social determinants, which it is suggested, both problematize people, and by
employing a Cartesian body/soul dichotomy, fails to acknowledge a person’s concept of health and
wellbeing, in particular in regard to the iTaukei people, a population with a demonstrated holistic
approach understanding of their health and the causes of illness.

A cultural determinants approach, which addressors factors negatively impact a person’s health and
wellbeing, and deliberately aims to incorporate that individual’s cultural framework for
understanding their health and wellbeing in healthcare delivery, is a possible approach that could be
incorporated in Fiji.

And it wasn’t just those who lived in remote villages. As an example, a friend of mine, a retired
secondary school principal just recently told me she was glad that a tabua had finally been presented
to the turaga ni vanua, after her niece had visited their vasu community without the proper
ceremony, people would stop getting sick. Clearly when it came to understanding causality and
treatment something else was going on.

I knew too that the phenomenon of iTaukei people not accessing healthcare until it was too late was
not uncommon. Conversations with the local health workers and friends of mine who work in health
care in Fiji lead me to understand that this was a consistent problem. As will become clear later on in
this presentation this leads to some tragic outcomes all of which are preventable.

Social Determinants of Health

There is a significant focus on social determinants of health within the policy. This assumes there are
things that needs to change and that addressing those wrongs (education levels, physical access to
healthcare, lack of knowledge, exercise rates, diet) will bring about the good changes the strategic
policy hopes to bring about. It implies there is something wrong with the population, and medical
professionals alone know what is wrong; they have done the research; they have studied
extensively; they have consulted international experts; brought them in to advise and applied means
of evaluation, asking questions that seek to answer the problems they conceive of as being problems
and therefore they know the solutions.

During the colonial period and the 50 years since independence, the population have been expected
to be compliant and to a considerable extent that continues to be the case.

Indigenous culture also tends to be rather status-conscious: the itaukei language is very specific in
means of showing respect; taboos on physical position reinforce age and gender hierarchies; even
the gaze is everted when speaking to an elder as means of showing humility and respect.

In other words, alongside the colonial experience and the reluctance of at least some of the
population to contribute openly, sits an indigenous system in which elites are expected to be
followed unquestioningly, and significant parts of the population effectively silenced.